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When discussing the side effects of the Haemophilus influenzae (Hib) vaccine with parents, which sign should the nurse mention for an infant receiving the vaccine?
- A. Lethargy
- B. Urticaria
- C. Generalized rash
- D. Low-grade fever
Correct Answer: D
Rationale: The correct answer is 'Low-grade fever.' A low-grade fever is a typical, mild side effect that can occur after the Hib vaccine is administered. It is a sign that the body's immune system is responding to the vaccine and is generally not a cause for concern. Lethargy, urticaria, and generalized rash are not commonly associated side effects of the Hib vaccine. Lethargy may be a sign of other issues, while urticaria and generalized rash are more indicative of allergic reactions rather than typical responses to the Hib vaccine.
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A child with a diagnosis of nephrotic syndrome is being treated with corticosteroids. What is an important nursing consideration?
- A. Monitor for signs of infection
- B. Monitor blood pressure
- C. Monitor for hyperglycemia
- D. Monitor for hypertension
Correct Answer: A
Rationale: When a child with nephrotic syndrome is undergoing treatment with corticosteroids, it is crucial to monitor for signs of infection. Corticosteroids can suppress the immune system, increasing the child's susceptibility to infections. Monitoring for signs of infection allows for early detection and prompt intervention. While monitoring blood pressure, hyperglycemia, and hypertension are important considerations in certain conditions and treatments, they are not the primary concern when a child with nephrotic syndrome is on corticosteroid therapy.
A nurse is evaluating a 3-year-old child's developmental progress. The inability to perform which task indicates to the nurse that there is a developmental delay?
- A. Copying a square
- B. Hopping on one foot
- C. Catching a ball reliably
- D. Using a spoon effectively
Correct Answer: A
Rationale: The correct answer is A: Copying a square. At 3 years old, children should be able to copy a square as part of their fine motor skill development. The inability to perform this task may indicate a developmental delay in fine motor skills. Choice B, hopping on one foot, typically develops around 4-5 years of age, so it is not a reliable indicator of a delay at 3. Choice C, catching a ball reliably, involves coordination skills that develop later in childhood, making it less relevant for a 3-year-old assessment. Choice D, using a spoon effectively, is more related to self-care and feeding skills rather than fine motor development, so it is not the best indicator of a developmental delay in this context.
The parents of a newborn with phenylketonuria (PKU) need help and support in adhering to specific dietary restrictions. They ask the nurse, "How long will our child have to be on this diet?" How should the nurse respond?
- A. "We are still not sure; you should discuss this with your health care provider."
- B. "If your baby does well, foods containing protein can gradually be introduced."
- C. "Your child needs to be on this diet at least through adolescence and into adulthood."
- D. "This is a lifelong problem, and it is recommended that dietary restrictions must be continued."
Correct Answer: D
Rationale: The correct answer is D: "This is a lifelong problem, and it is recommended that dietary restrictions must be continued." PKU requires a lifelong adherence to a specific diet low in phenylalanine to prevent cognitive and developmental issues. Phenylalanine buildup can lead to irreversible damage, making it crucial for individuals with PKU to maintain dietary restrictions throughout their lives. Choices A, B, and C are incorrect because they do not address the lifelong nature of dietary restrictions necessary for PKU management.
What are general guidelines when assessing a 2-year-old child with abdominal pain and adequate perfusion?
- A. Examining the child in the parent's arms
- B. Palpating the painful area of the abdomen first
- C. Placing the child supine and palpating the abdomen
- D. Separating the child from the parent to ensure a reliable examination
Correct Answer: A
Rationale: When assessing a 2-year-old child with abdominal pain and adequate perfusion, it is important to examine the child in the parent's arms. This approach helps reduce the child's anxiety, provides comfort, and can facilitate a more accurate assessment. Palpating the painful area of the abdomen first (choice B) may cause discomfort and increase anxiety in the child. Placing the child supine and palpating the abdomen (choice C) without considering the child's comfort and security may lead to resistance and inaccurate assessment. Separating the child from the parent to ensure a reliable examination (choice D) can further increase anxiety and hinder the assessment process. Therefore, examining the child in the parent's arms (choice A) is the most appropriate and effective approach in this scenario.
A 1-year-old child has a congenital cardiac malformation that causes right-to-left shunting of blood through the heart. What clinical finding should the healthcare provider expect?
- A. Proteinuria
- B. Peripheral edema
- C. Elevated hematocrit
- D. Absence of pedal pulses
Correct Answer: C
Rationale: In a congenital cardiac malformation causing right-to-left shunting, the nurse should expect an elevated hematocrit. This occurs because the body compensates for decreased oxygenation by producing more red blood cells. Proteinuria (Choice A) is not typically associated with congenital cardiac malformations causing right-to-left shunting. Peripheral edema (Choice B) is more commonly seen in conditions causing left-sided heart failure. Absence of pedal pulses (Choice D) is not a typical finding in congenital cardiac malformations causing right-to-left shunting.